In this section, you will find detailed descriptions regarding anatomy and technique specific to individual joints in the human body. For a general overview of the technique (including topics such as preparation, necessary equipment, anesthesia, etc.) please refer to the Procedure section.

Upper Extremity

 

Lower Extremity

UPPER EXTREMITY

Shoulder | Elbow | Wrist | Metacarpophalangeal | Interphalangeal

 
Shoulder

Anterior Approach (5,12)

-Patient should be sitting with shoulder in external rotation

 

-Needle entry occurs anteriorly:

below tip of coracoid process and medial to head of humerus

 

-Needle is directed posterolaterally to avoid arterial branches surrounding joint capsule.

 

Posterior approach(3)

-Analogous to the anterior approach

 

-Needle directed in the joint space just medial to the head of the humerus but from the posterior side of the shoulder

Elbow

Medial and Lateral approaches have been described. The lateral approach is preferred, because it avoids potential injury to the ulnar nerve (5).

 

Lateral Approach:

-Position elbow in 90 degrees flexion

-Fully pronate the forearm with palm facing downward

-Needle entry occurs within the triangle bound by:

  • Radial head
  • Lateral humeral epicondyle
  • Olecranon

-Needle is directed toward the medial epicondyle (10,11)

 

-With this approach, the physician can avoid hitting the radial nerve, which passes distal to the radial head near the elbow capsule (12).

Wrist

There are several approaches described in the literature. However, the "3-4 Portal" approach is recommended because there is less chance of damaging important vessels and tendons.

 

Portal approach:

-Position wrist in slight flexion and ulnar deviation (traction may facilitate exposure of the joint space)

-Locate the bony prominence over the dorsum of the distal radius (Lister's Tubercle).

-Needle insertion occurs dorsally, just distal to Lister's Tubercle and ulnar to the extensor pollicus longus tendon. A soft hollow spot should be palpable at the site of insertion, and this may be bulging and painful in the arthritic joint.

Metacarpophalangeal (5)

-Position hand with palm facing downward

-Traction to the digit is applied to facilitate joint entry

-Needle entry occurs:

  • Along the dorsal surface
  • Just medial or lateral to midline (avoids injury to central extensor slip)
  • Just proximal to base of proximal phalanx

Interphalangeal (5)

-Position hand with palm facing downward

-Traction to the digit is applied to facilitate joint entry

-Needle entry occurs:

  • Along the dorsal surface
  • Just medial or lateral to midline (avoids injury to central extensor slip)
  • Just proximal to base of middle or distal phalanx

 
LOWER EXTREMITY

Knee | Ankle | Metatarsophalangeal | Interphalangeal

 
Knee

The knee is the most commonly and easily aspirated joint. It has the largest synovial cavity (1). On clinical exam, large effusions can produce ballottement of the patella as well as suprapatellar or prepatellar swelling (8). There are several approaches to collecting fluid from this joint (9).

Inferior-medial approach

-Knee flexed 90 degrees

-Needle inserted in triangular area between the patella tendon, medial femoral condyle, and medial tibial plateau (10).

Medial approach

-Knee extended

-Needle is inserted 1 to 2 cm medial to the inner border of the patella at or just distal to the proximal edge of the patella (3).

-Needle directed posteriorly just beneath the patella. (This same technique can be utilized from the lateral aspect of the knee as well.)

These are the generally preferred approaches since they do not go through the patellar tendon.

 

Ankle

Use of local anesthetic within the joint space should be considered for comfort. Ultrasound guidance for needle insertion has been advocated by some physicians

 

Anteromedial Approach (5)

-Plantarflex the ankle

-Locate medial malleolus and anterior tibialis tendon

-Needle entry occurs:

  • One half inch above medial malleolus
  • One half inch lateral to anterior edge of medial malleolus
  • Medial to Anterior Tibialis Tendon

-Needle is advanced posteriorly (approximately one inch)

Metatarsophalangeal (4)

-Position patient supine

-Joint is flexed 15-20 degrees

-Traction is applied to facilitate joint entry

-Needle entry occurs:

  • Along dorsal surface
  • Just medial or lateral to midline (avoids central slip of extensor tendon)
  • Between metatarsal head and base of proximal phalanx

Interphalangeal (4)

-Position patient supine

-Joint is flexed to 15-20 degrees

-Traction is applied to facilitate joint entry

-Needle entry occurs:

  • Along dorsal surface
  • Just medial or lateral to midline (avoids central slip of extensor tendon)
  • Between head of proximal phalanx and base of more distal phalanx

 

 

 

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